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Soap note on headache for three weeks.
A 67 year-old woman comes to the ER with a headache for three weeks. Her neighbor, who brought her
to the ER, says the patient said the headaches had been getting worse and that she appeared to have
lost weight over the past several months. She has also been “confused” for the past week, but has been
able to walk on her own. Her hospital chart reveals a history of COPD, for which she takes inhalers, and
two admissions in the past six months for a right middle lobe pneumonia. Her last admission note
indicated she stopped smoking four months ago. On exam, she is a thin, elderly woman who is awake
and attentive, with normal temperature and vital signs and decresed breath sounds in the right middle
lung field. Her speech is fluent and well-articulated, but she identifies a watch as a wok, has difficulty
with three-step commands, and cannot repeat short phrases. There is a question of a right superior
quandrantanopia; her finger taps are slowed on the right.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies) would you like to obtain?
What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? How would you
monitor her condition and its treatment? What is the prognosis?
Case 41
A 67 year-old woman comes to the ER with a headache for three weeks. Her neighbor, who brought her
to the ER, says the patient said the headaches had been getting worse and that she appeared to have
lost weight over the past several months. She has also been “confused” for the past week, but has been
able to walk on her own. Her hospital chart reveals a history of COPD, for which she takes inhalers, and
two admissions in the past six months for a right middle lobe pneumonia. Her last admission note
indicated she stopped smoking four months ago. On exam, she is a thin, elderly woman who is awake
and attentive, with normal temperature and vital signs and decresed breath sounds in the right middle
lung field. Her speech is fluent and well-articulated, but she identifies a watch as a wok, has difficulty
with three-step commands, and cannot repeat short phrases. There is a question of a right superior
quandrantanopia; her finger taps are slowed on the right.
1) Summarize the case briefly, including neuroanatomic localization and pathogenesis.
2) What is the most likely diagnosis? Name 1-2 alternative diagnoses, and discuss briefly why these
are less likely.
3) What additional information (history, exam, laboratory or other studies) would you like to obtain?
What laboratory findings would you expect if your most likely diagnosis is correct?
4) Assuming your most likely diagnosis is correct, how would you manage this patient? How would you
monitor her condition and its treatment? What is the prognosis?